Abnormalities of male reproduction contribute to at least 30% of all infertility and possibly moreAbnormalities of sperm production commonly contribute to male infertility. These abnormalities may be abnormalities in the number of sperm (called oligozoospermia), abnormalities of sperm movement or motility (called asthenozoospermia) and abnormalities in appearance or morphology (called teratozoospermia). If one of these conditions is present the defect may be called single, if two are present the defect could be called double and if all three are present the defect may be called triple. An alternative name for a triple defect is oligoasthenoteratozoospermia, which is why many people prefer to call it a triple defect. Depending upon the extent of defects observed during a semen analysis, male factor infertility is described as mild, moderate or severe.The difficulty in making the diagnosis of male infertility from examination of the semen (commonly called a sperm count or semen analysis) is that sperm production is very variable over a period of time. In general it takes about two months to make a sperm and therefore testing at more frequent intervals is not ideal.

Normal values of semen variables according to the World Health Organisation:Standard tests

Volume: 2.0 ml or morepH : 7.2-8.0Sperm concentration: 20 million spermatozoa/ml or moreTotal sperm count: 40 million spermatozoa per ejaculate or moreMotility: 50% or more with forward progression (categories a and b) or 25% or more with rapid progression (category a) within 60 minutes of ejaculationMorphology: 15% or more with normal formsVitality: 75% or more alive

To be truly sure whether or not male factor infertility is present, it is important to examine semen on at least two occasions and on more than two occasions if one analysis shows an abnormality. It is also important to consider examination of semen by scientists that specialize in infertility such as those who work in an IVF laboratory such as Assisted Conception Australia.

Testicular disordersSperm production may be reduced when a man has a history of maldescent of one or both testes. Sometimes testicular injury or past treatment for cancer of the testis including chemotherapy can reduce sperm production by the testis. Some men carry genetic abnormalities in the number or arrangement of chromosomes that lead to a reduction in sperm production. The commonest of these are called Klinefelter syndrome and balanced translocations. Some men have genetic abnormalities of part of the Y chromosome. The Y chromosome is a sex chromosome which women do not have. Sometimes testicular production of sperm may be poor and unexplained. Sometimes there is a family history of male infertility but no identifiable genetic abnormality. There has not been sufficient research into the causes of male factor infertility and so many questions about the cause of male infertility remain unanswered.

Pituitary disordersThis is the most common cause of male infertility which is treated by treatment of the male rather than by assisted reproductive techniques such as IVF and ICSI. The pituitary, which is a pea-sized gland at the base of the brain, releases two hormones that control sperm and sex hormone production. These two hormones are called luteinizing hormone (LH) and follicle stimulating hormone (FSH). In pituitary disease and some rare brain disorders the production of these hormones can be low. This means that the testis does not receive the right signals to produce sex hormones and make sperm. These hormones can be given by injection to the man and sperm production by the testes can resume (or commence). A man may then be able to conceive a child through sexual intercourse if there are no medical problems with his partner that reduce her fertility.

Rarely the pituitary produces an excessive amount of prolactin and this suppresses sperm production. This can be corrected by the taking of a tablet and it is important that all men with poor sperm count have their prolactin checked.

Drug induced male infertilityThe commonest cause of reduced sperm count from drugs in our community is the administration of testosterone. Testosterone or other anabolic steroids are sometimes given inappropriately if a man complains of fatigue or reduced sexual performance. Sometimes they are taken inappropriately by a man wishing to enhance his exercise performance or muscular development. Testosterone reduces the sperm count and reduces the size of the testes. It may take several months for the testes to resume their normal function. Sometimes men with pituitary disease or testicular disease who have proven hormone deficiency are given testosterone and that is appropriate for their well being and bone health but those men must understand that their sperm production will be further reduced whilst they are taking testosterone. Some other drugs that can influence sperm production include marihuana, sulphasalazine (given for inflammatory bowel disease) and chemotherapy.

Retrograde ejaculation and disorders of ejaculationSometimes men may have ejaculatory defects though these are not common. Patients with spinal injury or men with diabetes commonly have difficulty with ejaculation. Sometimes sperm can be released into the bladder during ejaculation and this requires collection of a urine sample after masturbation and taking medication to avoid injury to the sperm by the urine. This condition is called retrograde ejaculation and is rare.

ObstructionObstruction to the outflow of semen is also rare but treatable. The commonest cause of obstruction is past vasectomy when a man believed he wished to have no further children but life circumstances changed. Sometimes obstruction can result from having two genes for a variant of cystic fibrosis. This is called congenital absence of the vas deferens. Sperm are generally present in normal sized testes and can be obtained by surgical sperm recovery. The female partner should be tested to check that she does not carry a gene for cystic fibrosis as 1:22 people do carry a gene for cystic fibrosis and there is a 1:4 risk of a baby being born with cystic fibrosis if both parents are carriers for the gene.

Lifestyle factorsIf a man has an abnormality of sperm production what can he do? Cigarette smoking reduces male fertility by a half and therefore cessation is recommended. If a man is obese he should lose weight to achieve the healthy weight range as obese men have reduced sperm counts compared to lean men. Marihuana use and excessive alcohol consumption (more than 14 standard drinks per week) should be ceased. More controversial and unproven treatments at this time include supplements of zinc, folic acid and multivitamins, and an organic diet. Regular ejaculation, at least two to three times per week, is thought to reduce the production of “aged” or damaged sperm and is therefore recommended for men attempting to conceive a pregnancy.

Long term implications of male infertility

Men with a reduced sperm count are at increased risk of testicular cancer and should therefore examine their testicles regularly. If they find a lump they should present promptly for examination and assessment. Some men, particularly those with severe reduction in sperm production may be at risk of male hormone deficiency. This may put them at risk of osteoporosis.

It is important that all men with male factor infertility are seen and examined by a specialist in the area. Assisted Conception Australia is committed to the improvement of men’s health by recognition of male infertility and its implications. Assisted Conception Australia conducts health seminars for both patients and doctors on male infertility. Dr Clare Boothroyd, endocrinologist and gynaecologist, is uniquely qualified to be an expert in this area.